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Jump to Page Content. Home Entry New Entry Logging Items A Matter of Balance Instructor Registry Arthritis Program Bingocize Certification Board of Health Nominations Boards and Commissions Application Breast Cancer Research/Education Trust Fund CHFS Boards and Commissions Application Chronic Disease Self-Management Program Coordinated School Health Team Registration COVID-19 KY Lab Daily Report Access Request Cultural Competency Questionnaire DAIL Suggestions DCBS Family Satisfaction DCBS Process Modernization Survey Diabetes Class Survey Eleventh Grade Immunization Survey First Steps EOB Foster Youth Exit Survey Health Facility Petition K-12 COVID-19 School Self-Reporting Access Request Kentucky Abortion-Inducing Drug Complaint Portal Kentucky Health Promotion Program Kentucky Radon Test Request Form KHIE Input For EHR Kindergarten Immunization Survey KY COVID-19 Community Outreach Events KY Diabetes Peer-Led Self-Management Program Application Local Health Personnel Training MCO Information Packet Requests OHRM - Training Survey OLD Exit Interview for Separating Employees Osteoporosis Program- Local Health Department PASSR Training Physical Disability Services Satisfaction Survey SAMHSA Grant Kickoff Meeting Seventh Grade Immunization Survey SUID Investigation Training Registration TBI	Page Content Physical Disability Services Satisfaction Survey Logging Survey Date: Invalid entry format First Name: Required Field Last Name: Required Field Phone Number: Invalid entry format Area Delevopment District: Required Field County: Required Field 1. When you contacted the Aging and Disability Resource Center, did you speak with a live person? YesNo If No, did you leave a voicemail? YesNo If Yes, when was your call returned? 24 Hours or Less More Than 24 Hours No Return Call Comments: Exceeding 5000 characters 2. Were they able to assist you and provide you with information on how to apply for services? YesNo Comments: Exceeding 5000 characters 3. Have you been assigned a case-manager? (If No, skip to question #11) YesNo*Required Field Comments: Exceeding 5000 characters 4. Do you know how to contact your case-manager if you have questions or need help? YesNo Comments: Exceeding 5000 characters 5. Have you had any issues reaching your case-manager and does he/she follow up with your requests and needs? YesNo Comments: Exceeding 5000 characters 6. Has your case-manager helped you find additional services or help that you need? YesNo Comments: Exceeding 5000 characters 7. Has your case manager provided documents containing the address, phone number, and contact person for the local Area Agency on Aging? YesNo Comments: Exceeding 5000 characters 8. Overall, how satisfied are you with your case-manager? Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Other Comments: Exceeding 5000 characters 9. Have you tried to contact the agency directly? YesNo If yes, were you able to speak to a live person? YesNo If No, did you leave a voicemail? YesNo If Yes, when was your phone call returned? 24 Hours or Less More Than 24 Hours No Return Call Comments: Exceeding 5000 characters 10. How satisfied are you with your services through the agency? Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Other Comments: Exceeding 5000 characters 11. Do you receive meals at the senior center or home delivered meals? (If No, skip to question #15) YesNo Comments: Exceeding 5000 characters 12. Are the meals presented in an appealing manner? Always Often Sometimes Rarely Never Comments: Exceeding 5000 characters 13. Are you satisfied with the flavor of the food? Always Often Sometimes Rarely Never Comments: Exceeding 5000 characters 14. Are you satisfied with the variety of food offered throughout the month? Always Often Sometimes Rarely Never Comments: Exceeding 5000 characters 15. Do you have any additional comments, complaints, or concerns that I have not covered? Exceeding 8000 characters Admin DAIL Staff: Comments: Exceeding 5000 characters Jump to Site Menu
Contact Us \| CHFS Site Map Privacy \| Disclaimer \| Individuals with Disabilities Copyright © 2009 Commonwealth of Kentucky All rights reserved.

KY Agencies \| KY Services Jump to Page Content. Secondary Menu About CHFS \| Contact Us \| Forms and Documents
Jump to Page Content. Home Entry New Entry Logging Items A Matter of Balance Instructor Registry Arthritis Program Bingocize Certification Board of Health Nominations Boards and Commissions Application Breast Cancer Research/Education Trust Fund CHFS Boards and Commissions Application Chronic Disease Self-Management Program Coordinated School Health Team Registration COVID-19 KY Lab Daily Report Access Request Cultural Competency Questionnaire DAIL Suggestions DCBS Family Satisfaction DCBS Process Modernization Survey Diabetes Class Survey Eleventh Grade Immunization Survey First Steps EOB Foster Youth Exit Survey Health Facility Petition K-12 COVID-19 School Self-Reporting Access Request Kentucky Abortion-Inducing Drug Complaint Portal Kentucky Health Promotion Program Kentucky Radon Test Request Form KHIE Input For EHR Kindergarten Immunization Survey KY COVID-19 Community Outreach Events KY Diabetes Peer-Led Self-Management Program Application Local Health Personnel Training MCO Information Packet Requests OHRM - Training Survey OLD Exit Interview for Separating Employees Osteoporosis Program- Local Health Department PASSR Training Physical Disability Services Satisfaction Survey SAMHSA Grant Kickoff Meeting Seventh Grade Immunization Survey SUID Investigation Training Registration TBI	Page Content Physical Disability Services Satisfaction Survey Logging Survey Date: Invalid entry format First Name: Required Field Last Name: Required Field Phone Number: Invalid entry format Area Delevopment District: Required Field County: Required Field 1. When you contacted the Aging and Disability Resource Center, did you speak with a live person? YesNo If No, did you leave a voicemail? YesNo If Yes, when was your call returned? 24 Hours or Less More Than 24 Hours No Return Call Comments: Exceeding 5000 characters 2. Were they able to assist you and provide you with information on how to apply for services? YesNo Comments: Exceeding 5000 characters 3. Have you been assigned a case-manager? (If No, skip to question #11) YesNo*Required Field Comments: Exceeding 5000 characters 4. Do you know how to contact your case-manager if you have questions or need help? YesNo Comments: Exceeding 5000 characters 5. Have you had any issues reaching your case-manager and does he/she follow up with your requests and needs? YesNo Comments: Exceeding 5000 characters 6. Has your case-manager helped you find additional services or help that you need? YesNo Comments: Exceeding 5000 characters 7. Has your case manager provided documents containing the address, phone number, and contact person for the local Area Agency on Aging? YesNo Comments: Exceeding 5000 characters 8. Overall, how satisfied are you with your case-manager? Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Other Comments: Exceeding 5000 characters 9. Have you tried to contact the agency directly? YesNo If yes, were you able to speak to a live person? YesNo If No, did you leave a voicemail? YesNo If Yes, when was your phone call returned? 24 Hours or Less More Than 24 Hours No Return Call Comments: Exceeding 5000 characters 10. How satisfied are you with your services through the agency? Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Other Comments: Exceeding 5000 characters 11. Do you receive meals at the senior center or home delivered meals? (If No, skip to question #15) YesNo Comments: Exceeding 5000 characters 12. Are the meals presented in an appealing manner? Always Often Sometimes Rarely Never Comments: Exceeding 5000 characters 13. Are you satisfied with the flavor of the food? Always Often Sometimes Rarely Never Comments: Exceeding 5000 characters 14. Are you satisfied with the variety of food offered throughout the month? Always Often Sometimes Rarely Never Comments: Exceeding 5000 characters 15. Do you have any additional comments, complaints, or concerns that I have not covered? Exceeding 8000 characters Admin DAIL Staff: Comments: Exceeding 5000 characters Jump to Site Menu
Contact Us \| CHFS Site Map Privacy \| Disclaimer \| Individuals with Disabilities Copyright © 2009 Commonwealth of Kentucky All rights reserved.